50 years after U.S. sounds alarm on smoking, work isn't done

NEW YORK (Reuters Health) - More than half of American men
and over a third of women were smokers on January 11, 1964, when
Dr. Luther Terry delivered the first Surgeon General's Report on
Smoking and Health.

Fifty years later, smoking rates have been cut by about
half, and a new study estimates that 8 million Americans have
been saved from premature smoking-related deaths.

"You look back in history to 1964 and in reality the world
was a very different place when it came to tobacco use and
smoking," Rear Admiral Boris Lushniak, the acting U.S. Surgeon
General, said.

A collection of reports released online today in the Journal
of the American Medical Association highlight achievements since
then, and areas that still need attention.

One paper estimates that about 17.7 million deaths between
1964 and 2012 were related to smoking. But without tobacco
control measures, an extra 8 million people would have died,
according to Theodore Holford of the Yale School of Public
Health in New Haven, Connecticut, and his colleagues.

The average American lifespan is more than two years longer
because those deaths have been averted, the researchers suggest.

"There is not a single thing one can point to," Holford said
of tobacco-control efforts that might have contributed to the
decrease in deaths. "There have been various things that have
taken place over time."

Those efforts include taxes on tobacco products, smoke-free
air laws, advertising regulations and measures to prevent youths
from starting to smoke.

'TREMENDOUS ACCELERATION'

Although Terry's 1964 report was not the first scientific
review to connect cigarettes and health issues, it is considered
a turning point in the battle against smoking and one of the
most important moments in public health history.

"The announcement gave tremendous acceleration to the study
of cigarettes and health," Dr. Otis Brawley, chief medical
officer of the American Cancer Society in Atlanta, told Reuters
Health.

Terry gathered 10 doctors, pathologists, chemists,
statisticians and other experts to review the available
evidence.

Because the tobacco industry in those days was so important
to the U.S. economy, Brawley said, the announcement was made on
a Saturday to lessen any impact on the stock market.

The committee's conclusion was that smoking causes lung
cancer in men and that men who smoke are more likely to die of
heart disease than those who don't.

Based on research since then, the U.S. Centers for Disease
Control and Prevention (CDC) estimates there is a two to
four-fold increase in the risk of heart disease and stroke for
smokers.

The CDC also estimates that smoking increases the risk of
lung cancer 13 times among women and 23 times among men.

LESS SMOKING, MORE SMOKERS

The U.S. is not alone in lowering smoking rates over the
past few decades, another new study found.

Researchers from the University of Washington found that
Canada, Mexico, Iceland and Norway cut the proportion of their
populations that smoke by more than half between 1980 and 2012.

Worldwide, however, the progress is mixed, said Dr.
Christopher Murray, one of the study's authors.

Data from 187 countries show that a smaller percentage of
the world's population was smoking in 2012 than in 1980. Still,
there are more smokers today, because of population growth.

About 41 percent of men and 11 percent of women worldwide
smoked in 1980, compared to about 31 percent of men and 6
percent of women in 2012.

The actual number of smokers, however, rose from an
estimated 721 million in 1980 to 967 million in 2012.

"That was a surprise," Murray said. "If you think about it,
we've known about the harms of smoking for 50 years or even
longer but the number of smokers keeps going up every year."

TROUBLE SPOTS

One approach to cutting the smoking rate involves targeting
efforts toward groups that are more likely to use tobacco.

People with mental illnesses, for example - including
depression, anxiety disorders and more severe conditions - had a
slower decline in smoking rates than people without mental
illnesses, another report says.

"It seems the tobacco cessation efforts have been working
for those without mental illness but haven't been working for
those with mental illness," said Benjamin Cook, the report's
lead author and a senior scientist at the Center for
Multicultural Mental Health Research at the Cambridge Health
Alliance in Massachusetts.

Cook and colleagues say people with mental illness
historically smoke at twice the rate of people without mental
illnesses.

If that is true, Cook said, "if you were able to decrease
those rates of smoking among people with mental illness, then
you can really make a dent in national rates."

THE ROAD AHEAD

"I think we know what prevents people from continuing to
smoke or not smoke at all," said Dr. Mariell Jessup, president
of the American Heart Association. Those include tobacco taxes,
smoke-free air laws and adequately funding state tobacco and
anti-smoking programs.

Persistent efforts to keep children from smoking are also
key, Brawley added.

"Very few smokers - less than 10 percent - start smoking as
adults," he said. "We really need to focus on keeping kids from
smoking."

Both he and Jessup also said attention needs to be paid to
electronic cigarettes - also known as e-cigarettes - which are
electronic devices that deliver nicotine through vapor instead
of tobacco smoke.

"E-cigarettes can be a very bad thing, can be a very good
thing and it can actually be both," he said. "We need to figure
that out."

Previous studies have suggested that people can use the
devices as smoking cessation tools, but some public health
advocates worry that e-cigarettes may introduce more people to
nicotine, the addicting chemical found in tobacco.

Lushniak believes there should be resolve to introduce an
end game within the next 50 years.

"The next stage really needs to be a resolution to move
ahead to this smoke-free generation concept," he said.

That concept will be part of an upcoming Surgeon General's
report celebrating the 50th anniversary of the original, he
added.

"The anti-smoking and tobacco control effort still needs to
be waged," Brawley said. "We are not finished."

SOURCE: http://bit.ly/WddS8K JAMA, online January 7, 2014.

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